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Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Weber Health Assessment in Nursing Chapter 14: Assessing Skin, Hair, and Nails.

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Presentation on theme: "Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Weber Health Assessment in Nursing Chapter 14: Assessing Skin, Hair, and Nails."— Presentation transcript:

1 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Weber Health Assessment in Nursing Chapter 14: Assessing Skin, Hair, and Nails

2 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Structure and Function of Skin The skin is a physical barrier that protects the underlying tissues and structures from microorganisms, physical trauma, ultraviolet radiation, and dehydration. Vital role in temperature maintenance, fluid and electrolyte balance, absorption, excretion, sensation, immunity, and vitamin D synthesis.

3 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Skin, Hair and Nails Skin- epidermis, dermis, subcutaneous layers Hair- vellus, terminal Nails- hard, transparent plates of keratinized epidermal cells

4 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement True or False? Sebum has some fungicidal and bactericidal effects.

5 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer True. Sebum has some fungicidal and bactericidal effects.

6 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement True or False? Asians and Native Americans have strong body odor.

7 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False. Asians and Native Americans have mild to no body odor because of decreased sweat production. Caucasians and African Americans tend to have a strong body odor.

8 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Skin Cancer Most common of cancers Three types: melanoma, basal cell carcinoma, squamous cell carcinoma Asians are less susceptible

9 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Risk Factors of Skin Cancer Sun exposure Nonsolar sources of ultraviolet radiation Medical therapies Family history and genetic susceptibility Moles Pigmentation irregularities Fair skin that burns and freckles easily; light hair Age

10 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Risk Factors of Skin Cancer (Cont’d) Male gender Chemical exposure Human papillomavirus Xerodrem pigmentosum Long-term skin inflammation or injury Alcohol intake; smoking Inadequate niacin in diet

11 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Risk Reduction in Skin Cancer Reduce skin exposure Always use sunscreen when sun exposure is anticipated Wear long-sleeve shirts and wide-brimmed hats Avoid sunburns Understand the link between sun exposure and skin cancer and the accumulating effects of sun exposure on developing cancers Have annual skin cancer screenings

12 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Risk Reduction in Skin Cancer Ensure diet is adequate in vitamin B 3 Examine the skin for suspected lesions –Use the ABCDE mnemonic to assess suspicious lesions: –Asymmetry –Border –Color –Diameter –Elevation

13 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which skin disorder may be caused by exposure to the sun? a. Acne b. Cancer c. Vitiligo d. Warts

14 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer b. Cancer. Rationale: Skin cancer may be caused by exposure to the sun. Acne, vitiligo, and warts are not caused by sun exposure.

15 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cultural Variations in Skin Cancer Lowest rates: Asians Highest rates: white Australians Most susceptible are people with pale white, freckled skin and red hair

16 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Risk Factors METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS Assess for hospital-acquired MRSA risk factors: –Having an invasive medical device –Residing in a long-term care facility

17 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Risk Factors METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (CONT.) Assess for community-acquired MRSA risk factors: –Participating in contact sports –Sharing personal items such as towels or razors –Suppression of the immune system function (e.g. HIV, cancer, or chemotherapy) –Residing in unsanitary or crowded living conditions (dormitories or military barracks)

18 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Risk Factors METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (CONT.) Working in the health-care industry Receiving antibiotics within the past 3 to 6 months Young or advanced age Men having sex with men

19 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Measures to Reduce Risk Factors Keep wounds covered. Do not share personal items. Avoid unsanitary or unsafe nail care practices. If treatment has been started, do not stop until recovery is complete. Use universal precautions when touching others to avoid contact with contaminated body fluids. Wash your hands. Clean sports equipment between uses to avoid spread of infection.

20 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing History: Present Health Concern Body odor problems Skin problems (rashes, lesions, dryness, oiliness, drainage, bruising, swelling, pigmentation) Changes in lesion appearance Feeling changes (pain, pressure, itch, tingling) Hair loss or changes Nail changes

21 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing History (cont.) Personal health history Family history Lifestyle and health practices Exposure to sun or chemicals Daily care of skin, hairs, nails Usual diet and exercise patterns

22 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Client Preparation Ask the client to remove all clothing and jewelry Have the client sit comfortably Ensure privacy Maintain comfortable room temperature

23 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Equipment Gloves Examination light and penlight Magnifying glass Centimeter ruler Wood’s light Examination gown or drape

24 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Skin Assessment: Inspection Note any distinctive odor Generalized color variations Skin breakdown Primary, secondary, or vascular lesions

25 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Skin Assessment: Palpation Lesions Texture Temperature and moisture Thickness of skin Mobility and turgor Edema

26 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Pressure Ulcer Risk Factors Perception Mobility Moisture Nutrition Friction or shear against surfaces Tissue tolerance decreased

27 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Pressure Ulcer Risk Reduction Inspect the skin at least daily and more often if at greater risk using risk assessment tool (such as Braden Scale or PUSH tool) and keep flow chart to document. Bathe with mild soap or other agent; limit friction; use warm not hot water; set bath schedule that is individualized. For dry skin: use moisturizers; avoid low humidity and cold air. Avoid vigorous massage.

28 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Pressure Ulcer Reduction (cont.) Use careful positioning, turning, and transferring techniques to avoid shear and friction or prolonged pressure on any point. Refer nutritional supplementation needs to primary care provider or dietitian, especially if protein deficient. Refer incontinence condition to primary care provider. Use incontinence skin cleansing methods as needed: frequency and methods of cleaning, avoiding dryness with protective barrier products.

29 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Scalp and Hair Inspection and palpation –General color and condition, cleanliness, dryness or oiliness, parasites, and lesions –Amount and distribution of scalp, body, axillae, and pubic hair

30 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Nail Assessment Nails –Inspection: Nail grooming and cleanliness, nail color and markings, shape of nails, –Palpation: Texture, assess texture and consistency, capillary refill

31 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Nails Risk Factors Nails in moist environment, especially walking in damp public locales or continuously wearing closed shoes; excessive perspiration. Nail injury, trauma, or irritation Immune system disorders such as diabetes mellitus and AIDS or on immunosuppressive medications. Skin conditions such as psoriasis or lichen. Some trades or professions Contagion from one digit to another or one person to another. Possibly family predisposition.

32 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Nails Risk Reduction Tips Wear leather shoes except for sports. Avoid wearing closed shoes all the time. Wear socks that wick away moisture. Avoid going barefoot in damp public areas. Avoid too much perspiration or water (wear gloves for hands). Avoid trauma to nails. Avoid unsanitary or unsafe nail care practices If treatment is started, do not stop until recovery is complete.

33 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Physical Assessment (cont.) Capillary refill Hair color and texture –Individuals of black American descent often have very dry scalps and dry, fragile hair.

34 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Self-Assessment Skin, Hair, Nails Refer to Box 14.1 Self Assessment: How to Examine Your Own Skin

35 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Normal and Abnormal Findings Share outcomes of assessment with peers

36 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Pressure Ulcer Stages Stage One Stage Two Stage Three Stage Four Unstagable

37 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Primary Skin Lesions Macule and Patch Papule and Plaque Nodule and Tumor Vesicle and Bulla Wheal Pustule Cyst

38 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Secondary Skin Lesions Erosion Ulcer Sacr Fissure

39 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Vascular Skin Lesions Petechia Ecchymosis Hematoma Cherry Angioma Spider Angioma Telangiectasis

40 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Common Nail Disorders Longitudinal ridging Half and half nails Pitting Koilonychia Yellow nail syndrome Paronychia

41 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Common Changes Aging Skin –Pale –Skin lesions –Dry –Loses turgor Hair: Thinner Nails: Thickened, yellow, brittle

42 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Validating and Documenting Findings Health promotion diagnoses Risk diagnoses Actual diagnoses Collaborative problems Medical problems


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